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Basics in Glaucoma Dr. Sharmila Glaucoma clinic. Glaucoma Glaucoma is an optic neuropathy with characteristic appearance of the optic disc and specific.

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Presentation on theme: "Basics in Glaucoma Dr. Sharmila Glaucoma clinic. Glaucoma Glaucoma is an optic neuropathy with characteristic appearance of the optic disc and specific."— Presentation transcript:

1 Basics in Glaucoma Dr. Sharmila Glaucoma clinic

2 Glaucoma Glaucoma is an optic neuropathy with characteristic appearance of the optic disc and specific pattern of visual field defects that is associated frequently but not invariably with raised IOP Glaucoma is an optic neuropathy with characteristic appearance of the optic disc and specific pattern of visual field defects that is associated frequently but not invariably with raised IOP

3 Classification of glaucoma Open angle glaucoma POAG NTG Juvenile open angle glaucoma Glaaucoma suspect Secondary open angle glaucoma Angle-closure glaucoma PACG with pupillary block Acute angle closure subacute angle closure CACG Secondary angle closure glaucoma with pupillary block Secondary angle closure glaucoma without pupillary block childhood glaucoma Primary congenital/infantile glaucoma Glaucoma associated with congenital anomalies Secondary glaucoma In children Classification of glaucoma Open angle glaucoma POAG NTG Juvenile open angle glaucoma Glaaucoma suspect Secondary open angle glaucoma Angle-closure glaucoma PACG with pupillary block Acute angle closure subacute angle closure CACG Secondary angle closure glaucoma with pupillary block Secondary angle closure glaucoma without pupillary block childhood glaucoma Primary congenital/infantile glaucoma Glaucoma associated with congenital anomalies Secondary glaucoma In children

4 Classification of glaucoma OPEN ANGLE GLAUCOMA CLOSED ANGLE GLAUCOMA DEVELOPMENTAL GLAUCOMA SECONDARY GLAUCOMA

5 POAG Adult onset Adult onset IOP > 21mm Hg IOP > 21mm Hg Open Angles Open Angles Glaucomatous nerve damage Glaucomatous nerve damage Visual field loss Visual field loss

6 Risk factors Age > 65 Age > 65 Black race Black race Positive family history Positive family history Myopia Myopia Thin Corneas Thin Corneas

7 Pathogenesis Increased resistance to aqueous outflow Increased resistance to aqueous outflow Ischaemic Theory Ischaemic Theory Mechanical theory Mechanical theory

8 pathogenesis Pathogenesis

9 Symptoms Usually asymtomatic Usually asymtomatic Rarely decreased visual fields Rarely decreased visual fields

10 Diagnosis of glaucoma History taking History taking Visual acuity and refractive state Visual acuity and refractive state Tonometry Tonometry Gonioscopy Gonioscopy Ophthalmoscopy Ophthalmoscopy Perimetry Perimetry

11 Tonometry Indentation tonometry-schiotz tonometer Indentation tonometry-schiotz tonometer Applanation tonometry Applanation tonometry variable force-goldmann Tonopen variable area- maklakov Non contact tonometer Non contact tonometer

12 Schiotz indentation Tonometry Body –footplate- rests on the cornea Body –footplate- rests on the cornea Plunger Plunger Weights- Weights- 5.5gm – permanently fixed. additional weights- 7.5g.10g,15g

13 Technique of schiotz tonometry Anaesthetise cornea Anaesthetise cornea Patient in supine position Patient in supine position Fixes on the target Fixes on the target Eyelids gently separated Eyelids gently separated Plunger rests on cornea. Plunger rests on cornea. Look for movement of the needle Look for movement of the needle Additional weights –if reading is <4 Additional weights –if reading is <4 IOP derived from conversion table IOP derived from conversion table

14 Sources of error Ocular rigidity Ocular rigidity High ocular rigidity-high hyperopia,long standing glaucoma,ARMD Low ocular rigidity –high myopia,osteogenesis imperfecta,miotic therapy,retinal surgeries Thick cornea-high value Thick cornea-high value

15 Other tonometers TONOPEN GOLDMAN APPLANATION

16 PERKINS TONOMETER PNEUMOTONOMETER

17 Gonioscopy Goniolens[direct] Goniolens[direct] Koeppe, layden, barken Gonioprism Gonioprism Goldman single mirror, two mirror, three mirror Zeiss four mirror Posner four mirror

18 Normal angle structures Ciliary body band Ciliary body band Scleral spur Scleral spur Trabecular meshwork Trabecular meshwork Schwalbe’s line Schwalbe’s line

19 Ophthalmoscopy Disc Disc Focal atropy Concentric atrophy Deepening of the cup Advanced glaucomatous cupping Vascular changes Vascular changes Haemorrhage,baring of vessels, bayonetting Retinal nerve fiber layer changes Retinal nerve fiber layer changes Peripapillary atrophy Peripapillary atrophy

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21 Perimetry Kinetic Kinetic Static Static Visual fied defects Visual fied defects Paracentral scotoma Paracentral scotoma Seidel scotoma Seidel scotoma Arcuate scotoma Arcuate scotoma Double arcuate scotoma Double arcuate scotoma Nasal step Nasal step

22 Angle Closure Glaucoma With pupillary block With pupillary block Without pupillary block Without pupillary block Diagnosis depends on : Diagnosis depends on : Anterior segment examination Anterior segment examination Gonioscopy Gonioscopy

23 Risk factors Age Age Gender Gender Asians, Chinese, Eskimos Asians, Chinese, Eskimos Family history Family history Hypermetropia Hypermetropia

24 Pathogenesis Increased opposition between iris and lens enhance the degree of pupillary block Increased pressure in posterior chamber Increased peripheral iris bowing Iris Bombe High IOP

25 Types Latent Latent Subacute Subacute Acute congestive Acute congestive Post congestive Post congestive Chronic Chronic Absolute Absolute

26 Acute Congestive Glaucoma Symptoms Symptoms Severe pain and vomiting Severe pain and vomiting Unilateral visual loss Unilateral visual loss coloured haloes coloured haloes Headache and vomiting Headache and vomiting

27 Signs Shallow AC Shallow AC Corneal edema Corneal edema Semi dilated pupil Semi dilated pupil High IOP High IOP Closed angles Closed angles

28 Treatment Immediately Immediately 2% Pilocarpine 2% Pilocarpine Steroid eye drops Steroid eye drops Β blockers Β blockers Analgesics and antiemetics Analgesics and antiemetics Lie in supine position Lie in supine position I.V. Mannitol + Oral T. Diamox I.V. Mannitol + Oral T. Diamox

29 Treatment MEDICAL MEDICAL AFTER CORNEA CLEARS AFTER CORNEA CLEARS LASER PI LASER PI IF NOT POSSIBLE IF NOT POSSIBLE TRABECULECTOMY TRABECULECTOMY

30 Cont.d… After 1 hr: After 1 hr: Pilocarpine 2% Pilocarpine 2% Yag PI Yag PI After 11/2 hr: After 11/2 hr: If IOP is still high If IOP is still high 50% oral glycerol 50% oral glycerol 20% Mannitol (1-2g/kg) I.V. over 45minutes 20% Mannitol (1-2g/kg) I.V. over 45minutes

31 Laser Iridotomy Clear corneas Clear corneas Less than of angle by PAS Less than of angle by PAS Surgery: Trabeculectomy Surgery: Trabeculectomy

32 Congenital Glaucoma 1:10,000 births 1:10,000 births 65% are boys 65% are boys Pathogenesis: Pathogenesis:Maldevelopment of the angle of anterior chamber

33 Classification Congenital Glaucoma Congenital Glaucoma Infantile Glaucoma Infantile Glaucoma Juvenile Glaucoma Juvenile Glaucoma

34 Clinical Features Corneal edema Corneal edema Buphthalmos Buphthalmos Breaks in DM Breaks in DM Optic disc cupping Optic disc cupping

35 Diagnosis Increased IOP Increased IOP Increased Corneal diameter > 11mm at 1yr Increased Corneal diameter > 11mm at 1yr > 13mm > 13mm Treatment: Treatment: Goniotomy Goniotomy Trabeculotomy Trabeculotomy trabeculectomy trabeculectomy

36 Lens related Glaucomas Phacolytic: Phacolytic: Hyper mature cataract Hyper mature cataract Corneal edema Corneal edema AC reaction – psuedo hypopyon AC reaction – psuedo hypopyon Open angles Open angles

37 Treatment Anti glaucoma drugs Anti glaucoma drugs Topical antibiotic steroids Topical antibiotic steroids surgery surgery

38 Phacomorphic Galucoma Intumscent cataractous lens Intumscent cataractous lens Shallow anterior chamber Shallow anterior chamber Treatment: Treatment: Antiglaucoma drugs Antiglaucoma drugs Laser iridotomy Laser iridotomy surgery surgery

39 Neo vascular Glaucoma Retinal ischaemia Retinal ischaemia NVI NVI NVA NVA OPEN ANGLE OPEN ANGLE ANGLE CLOSURE ANGLE CLOSURE

40 Causes Ischeamic CRVO Ischeamic CRVO Diabetes Mellitus Diabetes Mellitus Miscellaneous Miscellaneous Carotid disease Carotid disease Intra ocular tumor Intra ocular tumor Long standing RD Long standing RD

41 Symptoms & Signs Decreased visual acuity Decreased visual acuity Congestion of Globe Congestion of Globe Very high IOP and corneal edema Very high IOP and corneal edema Severe pain Severe pain Aqueous flare Aqueous flare NVI NVI Gonioscopy - NVA Gonioscopy - NVA

42 Treatment Medical – topical Atropine & steroids Medical – topical Atropine & steroids Retinal ablation / - DIODE CPC Retinal ablation / - DIODE CPC Surgery: Surgery: Trab with MMC Trab with MMC Aqueous drainage shunts Aqueous drainage shunts Retrobulbar alcohol injection Retrobulbar alcohol injection Enucleation Enucleation

43 Treatment Modalities in glaucoma Medical Medical Laser Laser Surgery – Trabeculectomy Surgery – Trabeculectomy combined surgery combined surgery

44 Anti Glaucoma Drugs Β blockers Β blockers Decreases IOP by decreasing aqueous secretion Decreases IOP by decreasing aqueous secretion Contra indications: Contra indications: Congestive cardiac failure Congestive cardiac failure Heart block Heart block Bradycardia Bradycardia Bronchial asthma Bronchial asthma

45 Side effects Iotim, Nyolol, Glucomol 0.5% bd Iotim, Nyolol, Glucomol 0.5% bd Ocular Systemic Ocular Systemic allergyBradycardia, Hypotention SPK’sBroncho spasm tear secretionHallucination, head ache nausea, dizziness

46 Alpha 2 Agonists Brimonidine, apraclonidine Brimonidine, apraclonidine Mechanism: Mechanism: Decreases aqueous secretion Decreases aqueous secretion Increases uveo scleral outflow Increases uveo scleral outflow Side Effects: Side Effects: Allergic conjunctivitis Allergic conjunctivitis Xerostomia Xerostomia Drowsiness and headache Drowsiness and headache

47 PROSTAGLANDIN ANALOGUES Mechanism Mechanism Decreases IOP by increasing uveoscleral outflow Decreases IOP by increasing uveoscleral outflow Latanoprost F 2 α analogue.005% Latanoprost F 2 α analogue.005% Travoprost 0.004% Travoprost 0.004% Bimatorpost 0.3% Bimatorpost 0.3% Unoprostone 0.15% BD Unoprostone 0.15% BD

48 Side Effects Conjunctival hypereamia Conjunctival hypereamia Eye lash growth and hyperpigmentation of periorbital skin Eye lash growth and hyperpigmentation of periorbital skin Anterior uveitis Anterior uveitis Cystoid macular edema Cystoid macular edema

49 MIOTICS Pilocarpine 1% 2% 3% 4% QID Pilocarpine 1% 2% 3% 4% QID Parasympathomimetic stimulates muscarinic receptors in sphincter pupillae & ciliary body Parasympathomimetic stimulates muscarinic receptors in sphincter pupillae & ciliary body In POAG – increases aqueous outflow In POAG – increases aqueous outflow In PACG – opens the angles In PACG – opens the angles

50 Side Effects Miosis Miosis Browache Browache Myopic shift Myopic shift Visual field defect Visual field defect

51 Carbonic Anhydrase Inhibitors Carbonic Anhydrase Inhibitors Inhibits aqueous secretion Inhibits aqueous secretion Topical CAI Topical CAI Dorzolamide (Trusopt) Dorzolamide (Trusopt) Brinzolamide (Azopt) Brinzolamide (Azopt) Systemic CAI Systemic CAI Acetazolamide 250mg BD Acetazolamide 250mg BD

52 Side Effect Parasthesia Parasthesia Malaise Malaise GI upset GI upset Renal Stone Renal Stone Blood dyscrasias Blood dyscrasias

53 Hyper Osmotic Agents Glycerol 1g / kg in 50% solution Glycerol 1g / kg in 50% solution Mannitol 1-2g/kg in 20% solution Mannitol 1-2g/kg in 20% solution Side Effects: Side Effects: Cardiac or renal failure Cardiac or renal failure Urinary retention Urinary retention Head ache, nausea Head ache, nausea

54 Lasers in Glaucoma Laser Iridotomy: Laser Iridotomy: Indications: Indications: PACG PACG Occludable angles Occludable angles SACG with pupillary block SACG with pupillary block Combined mechanism glaucoma Combined mechanism glaucoma

55 Laser PI prerequisites prerequisites Instil 1% Apraclonidine Instil 1% Apraclonidine Miotic pupil Miotic pupil Laser settings 4-8 mJ Laser settings 4-8 mJ Post laser steroid eye drops Post laser steroid eye drops Abraham lens Abraham lens

56 Complications Bleeding Bleeding Iritis Iritis Corneal burn Corneal burn Glare Glare Diplopia Diplopia

57 Surgery Trabeculectomy: Trabeculectomy: A conventional filtering procedure creates a new channel for aqueous outflow between the anterior chamber and subtenons space without the use of an artificial device A conventional filtering procedure creates a new channel for aqueous outflow between the anterior chamber and subtenons space without the use of an artificial device Partial thickness Partial thickness Full thickness Full thickness

58 Management of coexistent cataract and glaucoma

59 Complications Wound leak Wound leak Excessive filteration Excessive filteration Pupillary block Pupillary block Malignant glaucoma Malignant glaucoma Hypotony Hypotony Choroidal detachment Choroidal detachment

60 Failing bleb SIGNS Injection Vascularisation Thickening Localization High domed Bleb Normal / High IOP Low IOP Initial few weeks critical

61 Failing filtration Frame work for Classification IOP Bleb

62 Failing filter – High IOP Low localized Bleb External - Subconjunctival fibrosis -Tight scleral flap sutures Internal - Sclerectomy obstruction

63 Failing filter – High IOP High domed bleb – encapsulated bleb or Tenon’s cyst

64 Failing filter - Low IOP Low bleb- Bleb leak Elevated diffuse bleb- Over Filtration hypotony

65 Bleb Failure Argon laser suturolysis 0.2sec 50µ mw Argon laser suturolysis 0.2sec 50µ mw Digital massage Digital massage Topical steroids Topical steroids 5FU injection 5FU injection DF Nd yag laser DF Nd yag laser Needling of tenons cyst Needling of tenons cyst

66 REFRACTORY GLAUCOMA AQUEOUS DRAINAGE IMPLANTS AQUEOUS DRAINAGE IMPLANTS

67 Refractory glaucomas Cyclo destructive procedures Cyclo destructive procedures

68 New diagnostic and surgical procedures Central corneal thickness assessment Central corneal thickness assessment

69 OPTICAL COHERENCE TOMOGRAPHY

70 ULTRASOUND BIOMICROSCOPY

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72 Classification of glaucoma OPEN ANGLE GLAUCOMA CLOSED ANGLE GLAUCOMA DEVELOPMENTAL GLAUCOMA SECONDARY GLAUCOMA

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